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Friday, August 10, 2012

Institute of Medicine: Obesity is not caused by lack of willpower

In a 48-page report, the Institute of Medicine “refutes the idea that obesity is largely the result of a lack of willpower on the part of individuals.” [You know the IOM, the same folks who brought you the “98,000 people are killed each year by medical errors” report, the accuracy of which has been challenged.]

According to a spokesman for the IOM, “"When you see the increase in obesity you ask, what changed? And the answer is, the environment. The average person cannot maintain a healthy weight in this obesity-promoting environment."

The report goes on to say, “People cannot truly exercise ‘personal choice’ because their options are severely limited, and biased toward the unhealthy end of the continuum."

Quoting further from an article about this revelation from the IOM, “The panel recommended tax incentives for developers to build sidewalks and trails in new housing developments, zoning changes to require pedestrian access and policies to promote bicycle commuting.”

"We've taken fat and sugar, put it in everything everywhere, and made it socially acceptable to eat all the time. We're living in a food carnival, constantly bombarded by food cues, almost all of them unhealthy," said David Kessler, former head of the U.S. Food and Drug Administration. Maybe Kessler should have done something about this when he was in charge of the FDA.

Are they serious?

Things like this really aggravate me. [Lots of things aggravate me.]

Everyone who drinks alcohol doesn’t become an alcoholic. The IOM says it's not willpower. How is it then that some who are exposed to the same environmental factors and food cues as obese people manage to maintain a normal weight?

How much did the IOM’s 48-page report cost and who paid for it?

Do you think building sidewalks and promoting bicycle commuting will really decrease obesity?

What do you think of the IOM report?

A version of this post appeared on Sermo yesterday. Most of those who commented felt that the IOM was out of touch with reality or al least, mistaken.

I think that ignoring metabolic issues (such as secretion of both exocrine and endocrine chemicals) would be leaving out a huge piece of the picture.

Environment certainly plays a part, especially in regards to cost and the brain washing of commercials. Cheap food is usually crappy food, chock full of fillers and chemicals and calories. Food grown close to home, grown with minimal impact on the environment, that costs more. And prep work for these foods take more time, and those with multiple jobs, working weird or long hours will find it harder to put meals together rather than just grabbing something they can heat up in the microwave.

I am lucky that my body type is such that exercise has a huge impact and though I love cooking and creating food, I don't feel the need to eat all of it. But I don't think that it is due to my willpower that I am in decent body condition. My sister does 5 Ks and boot camp classes and her BMI is pretty high. She has HUGE willpower.

Obesity is multi-factorial and seeking sugar/fat (easy calories to burn) is literally built into our DNA. The people that ate these foods and were able to store fat were more likely to survive. As these foods showed up, ready made on the shelves, being pushed into the faces of consumers, of course our evolutionary drives kicked in, and those foods are preferentially chosen.

Some people have a lack of will power, some people have a lack of time, some people are cursed with a body type that stores fat.

Anonymous again: Sure SMHDVM, you are in many ways right. Still, I am one of those who easily store fat (an evolutionary survivor I guess ?) - still, just by using very simple maths, I have managed to control the situation. Constant control over consumption and 20 minutes of exercise daily, keeps my BMI in control. No need for Obesity-surgery at all.

The ultimate downfall would to be obese, followed by Robotic Obesity-surgery, followed by postoperative complications and finally followed by the increased risk of repeated renal calculi formation and finally repeated treatments for that problem and so forth and so forth...

by pure happenstance, came across this TedxTalk which seems relevant:“@jvrbntz: TED talk from an EM physician The future of patient-centered care: Dave Moen at TEDxUMN: http://t.co/y1mCQ0J0 via @youtube”

We are way too accepting of the obese. We should be sure to mock and scorn the obese more often. We should make fun of those who don't exercise or who frequent McDonald's.

Surgeons should be willing to say "you are just too fat for me to do surgery". Or PCPs should be able to say "Lose weight or you will be dead soon". Radiologists should put in their impression: 1) this patient is fat.

Obstructive sleep apnea should be renamed Fat Man's Sleep disorder. Type 2 DM should be called Preventable hyperglycemia of the morbidly obese. The term Morbid obesity should be replaced by RF or Really Fat.

We should set tax scales based upon BMIs >35. The obese should have to pay double for a seat on an airplane, for a hospital bed, a seat in the movies...etc

This is yet another confirmation that we live in a victim mentality world. Society has devolved to a state where the individual cannot even be held responsible for decreasing caloric intake or increasing calories burned through physical activity.

Metabolism rates vary, but if there is a person who converts X calories consumed into X+Y calories that are either burned or stored as fat, we have just discovered the solution to the energy crisis...

I love how these types of studies/articles bring out the just say no folks - i.e., to lose weight, simply eat less and exercise more. Yes it works. So does abstaining from alcohol for an alcoholic, yet there's more to staying away from it than "will power". You can interpret "will power" as something in the psychological/physiological makeup that is easier for some than others and varies depending on the area in which it is applied. Some can say no to excessive drinking easier than eating or spending money for example.

If "will power" were all it took to lead a perfect life, we would have no obesity, alcoholism, or addictions as well as no debt crises (after all, it's only a matter of saying no to buying what I can't afford), energy crisis (using more energy than I require simply because I can) or other excesses than could be solved by just saying no.

In my humble opinion, until we can understand what motivates and drives us as individuals, we cannot make superficial statements about "will power" and its applications.

If the cause was fully understood, then we wouldn't be in the situation of >50% adults being overweight or obese (if I remember the stat correctly for Australian society). There's an awful lot of factors working against healthy weight: environmental factors as stated, but even the nutritional status of the mother and grandmother of each individual (influences tendency for the fetus to store fat), birthweight of babies (U-shaped association between birthweight and risk for subsequent obesity,with 3.1kg being ideal. Median birthweight in the West is about 3.5kg,which automatically puts those children at increased risk of obesity, cardiovascular disease and diabetes in adulthood, but then same goes for the low birthweight babies too..), socioeconomic status, breastfed vs bottlefed (formula or breastmilk in bottles is associates with increased risk of childhood obesity), and probably a heap more I don't know about. Then there's the endocrine issue of once a person gains weight, even a year after weight loss, levels of "hungry hormones" remain the same, which tell the person to eat more and gain back the weight. There seem to be epigenetic changes that make people stay overweight: it's absolutely not as simple as "energy in, energy out", otherwise the diets would work. There's undoubtedly more that I don't know or can't remember from endocrinology lectures, but I do remember it really challenged my views on why people are overweight or obese. It's nowhere near as simple as telling people to control themselves and eat better.

Steve et al, thanks for the well considered comments. You make some good points. The only problem with all of your complex theories is that they support the notion that obesity is a disease that the obese are afflicted with and therefore they can't help themselves.

No question, weight loss is about calorie consumption exceeding calorie expenditure. Research shows that cutting calories (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2949959/) to the tune of around 1200/day does result in weight loss; in this study the mean BMI was 36 (obese) and avg weight lost was 11% at one year and 7% at two years. That amount may not make the patient "look" thin but can lead to improvements in health. For patients who have BMI > 40, and cannot easily exercise because of that excess weight, bariatric surgery is the ONLY treatment option shown to produce SIGNIFICANT weight loss ( > 50% of excess weight). Again, the 500 lb patient who loses half their excess body weight may not look thin, but will have greatly improved their health. Complication and mortality rates for bariatric surgery are acceptable if the surgeon is working at a Center of Excellence where outcome data is tracked.Bottom line: eating < 1200 calories per day FOREVER is daunting for many people. Unlike smoking, one cannot entirely give up eating. Is it about will power or the lack of it--of course it is. Eating is a biological, life sustaining instinct. But, what portion of which food we eat, is our choice. Small steps that might help mitigate the current obesiogenic environment:1. Eliminate sugar-drinks in schools, hospitals and other public buildings; unnecessary calories2. Require the food industry to display in large print-- accurate nutrition information (all restaurants, products) 3. Re-education on portion sizes4. Better access to fresh foods for everyone5. Don't market processed sugar foods to kids6. and, YES make it possible to safely WALK places!! Where do you live Skeptical? I live in a suburb and when I walk my dog (not on a sidewalk in some areas) I am in danger of being road-kill. More parks, sidewalks and safe places to "recreate" (bike and hiking trails)make it easy and inexpensive to get out and exercise. Not everyone can afford a monthly gym membership but many people can (only) afford a fast-food-type meal.

I want to conclude with mention of a pet peeve. I think the reason obesity bias is so prevalent, pervasive and acceptable is because we can "see it". You can't visually see other behaviors with deleterious effects, that also involve a lack of "willpower": like smoking, gambling, drug addiction,alcohol addiction, unsafe sex, sex addiction, pedophilia, rapist, child abuser, wife beater, serial killer. If you see a THIN person walking down the street, nicely dressed, they may be any of those "bad" things mentioned, but you will not perceive that individual unfavorably (initially). (And, don't bring up that smoking, drugs, alcohol are not the same as being a serial killer--That is not my implication--I include smoking only because it is the #1 preventable cause of death in the USA. NOT because I think people who smoke are bad people--The effects of smoking, alcohol, drugs etc are bad. Not necessarily the people who use)I am simply underscoring that you can't SEE those behaviors on the exterior the way you can see excess adiposity. Just a reminder that the slippery slope of judging others is lined with people who have their own "unseen" flaws that may ALSO be the result of "will power" deficits.

(Case in point--Jerry Sandusky..perceived as a "good guy" by an educational institution and a community. Yet he clearly lacked the "will power" required to keep from molesting young boys. That lack of will-power, not readily visible to the casual observer,was ignored--for years. To the detriment of many.)DD

Anon, Thanks for the comments. I agree with some of your points. I have blogged about hospitals and schools serving unhealthy food. [http://skepticalscalpel.blogspot.com/2010/09/junk-food-and-hospitals.html]

I live in a suburb too. There are open spaces, parks and some sidewalks. One can find a place to walk if one tries.

Your point about seeing obesity and not the other flaws is a good one.

I've been thin, fat, obese, morbidly obese, obese and now am merely fat. I've lost 65 pounds over the last 16 years, and have about 45 more pounds to go to be roughly average. I was harassed constantly about my weight in school, and, trust me, it did not help make me a thin person. It made me really pissed off. On the other hand, it did train me that most people's opinions do not matter.

I have a mixed viewpoint on the issue of obesity and health.

Genetics do matter, but they are not necessarily destiny. I come from a long line of fat people. Carbs and proteins taste great to me. While I've learned to eat some vegetables and fruits, I never, ever crave them, as much as I should. I'm still learning.

No matter what your weight is, you have to accept yourself, be reasonably active, and eat sensibly. There are a lot of self-hating thin and fat people out there.

Gym classes in school need to be dramatically rethought. When I was in school in the '60s and '70s, they focused on sports. Some of us were and have always been wretched at sports. They ought to be focused more on activities and health. They should expose kids to sports, but if the kids happier walking the track than trying to hit a baseball, that should be considered an acceptable gym activity.

The interaction of obesity and the medical community is, frankly, awkward. During the 90s, I remember being shocked by being asked "do you mind if we weigh you?" While people need to be respected by clinicians no matter what their weight, information like their weight, height, cholesterol, blood sugar (and so on) need to be recorded. Fat people should not be harassed, but they do need to be reminded about good eating habits and activity no matter what their weight is.

I think the thing that made me finally start to lose weight was the introduction of gastric bypass. While I eat less than I used to and do exercise more, I love a good meal. I still find eating very pleasurable, despite its potential dangers. I was at the point where gastric bypass was an option, and I knew I didn't want to have eating be that unpleasant.

I opted to start walking. I just did little things at first, like parking across a parking lot from my work or a store. Right now, I'm unemployed and am walking 3-4 miles a day.

I think one of the other big problems with attitudes towards obesity and dieting is this idea that loosing weight can be easy and fast. It isn't. Relearning how to eat is hard. But, the more we can non-medicalize loosing weight (focusing on diet and exercise rather than drugs and surgery), but better we all be in the long run.

Laurie, thank you for the comments. I'm not sure who you are quoting but it wasn't I. I did exaggerate a bit to make a point. Your points are well taken. I don't know if you saw the 4 minute clip of the overweight news anchor from Wisconsin who responded to a guy who emailed her criticizing her for her weight. It was very good and opened my eyes a bit.

Sorry the "way to accepting of the obese" line was a comment from one of the anonymous posters.

I don't think there is "a" solution. Obesity/anorexia are tricky conditions and relate to upbringing, education, community planning, marketing...there are many unrelated pieces to a person's size. Medical personnel need to be respectful (and generally are), but need to have good information about nutrition available. And I understand nutrition isn't generally taught in med school.

So, I'm a first-year med student, and I have a MS in nutrition. I got to study obesity with a researcher in the field, and it was very eye-opening. Most of you who have commented have no idea what you're talking about. This is a very complex issue, involving environment, hormones, evolution, and lots of factors that we don't understand yet (viruses, gut flora, etc). I highly reccommend reading (especially chapter six) of " Health At Every Size", which is available electronically for about two bucks at Amazon. It's not about willpower, though if you're thin it's fun to think so! Cruelty and discrimination towards the obese, and assumptions made about their character, put you on the wrong side of history AND science.

It's great that you are so sure of yourself as a first-year med student. I agree that there are many factors leading to obesity. How does your view of the issue reconcile the fact that a number of people have in fact overcome their obesity by dieting and exercise? The way you apparently see it, it can neither be prevented or cured.

I'm sure of myself because of my training as a nutritionist, not as a med student! Very few people maintain significant weight loss long-term. Less than 5% of people who try. When you look at studies on weight loss, most are less than 5 years (or less than 5 months), and the longer-term ones usually define success as 5-10% loss; fat people who are slightly less fat. I do think it can be prevented in many cases, and that is the key, but it requires big-picture changes...and early in life. Another study just came out indicating that, the longer a mouse is overweight, the harder it is to lose. That has been seen in some human studies as well (again, this doesn't really fit with the willpower theory).

Somewhat lost amid all the comments is that a major point of my post is that I don't think building sidewalks and promoting bicycle riding is going to work. And I didn't need a 48-page report to tell me that.

What do you think of the recent report that noted bariatric surgery patients replace their food addiction with addictions to alcohol, cigarettes or drugs? (http://www.ncbi.nlm.nih.gov/pubmed/23070230)

I hadn't seen that, that's interesting. It makes sense, I think. Gastric bypass patients are often stressed out and dissapointed in the aftermath of surgery. I also wonder about the impacts of the surgery (and subsequent starvation) on neurotransmitter levels. As for your lost point, I don't think those things in and of themselves will solve the problem, but I do think that environment and social norms are key to preventing weight gain in those people for whom it is preventable. Exercise isn't great for (substantial, sustainable) weight loss, but it is really important for preventing weight gain, and making it a normal part of life again would seem like a step in the right direction. No?

I think exercise is very important. The combination of better food choices and exercise has enabled me to lose 25 lbs and keep it off for three years. Using the same method, my wife has lost 60 lbs and maintained her weight as well. She is no longer obese. It can be done.

I want to add a dimension that has not been mentioned, that of unnatural food additives causing obesity. Consider, for example, the food additive glutamate (MSG, monosodium glutamate). Yes, it is an amino acid, and a neurotransmitter, but it is natural to eat a balanced mixture of bound amino acids in the form of protein, not a food enriched in one particular "taste-enhancing", free amino acid/neurotransmitter. There are data that persons consuming MSG will be heavier than other people, AFTER controlling for calorie intake. Aspartame may act in the body in a similar way. Aspartame passed the FDA in the 1980s because of corrupt politics, not good science. (Aspartame is in "diet" pop, which unsurprisingly fails in its purported purpose.)

Artificial food additives are abundant today. Americans take better care of their cars than they do of their own bodies. Calories in vs. calories out, is not the whole story; a simplistic view of diet and exercise is not the total answer. We should avoid all processed foods/fast food/pop/etc, take our calories earlier in the day if possible, and avoid gaining weight if possible, because once the pounds are on, the body tries to keep them on. I have never been fat or obese and never want to find out what it is like.

I find it angering that additives such as MSG can be disguised on food labels, legally, with terms such as "natural flavors". The obesity epidemic corresponded with the rise of the food industry, factory farming, and artificial foods. We need to boycott the food industry and bring back the housewife and mother and give her the time and energy, and the respect, that she deserves.

The problem with obesity is not a lack of willpower but hunger, and our general approach to weight control and weight loss. Forty years of low fat dietary guidelines and we as a nation have been surprisingly compliant in following them with the outcome an obesity epidemic. Surprise. No.

The root of the problem overall lies within nutritional science. It struggles in its inability to separate the effects between digestive consumption and metabolic processes, and the differences between acute and chronic effects, and the intermediate factors of disease and their relationship to disease and disease outcomes. Then there are economic and political forces inside and outside the science that drive and cloud the research. It even affects and determines what is researched. And lastly, hypotheses, concepts and scientific findings not found in political alignment within the existing field are attacked and the advocates maligned by their peers. There is no wonder why we have an obesity epidemic. We have the wrong approach with all the wrong answers, and can we can’t seam to change and get it right.

So how we should address obesity? This is critical because the root causes of obesity also the causes cardio and vascular diseases, type 2 diabetes, gout, kidney and liver diseases for starters. The root cause is now accepted to be metabolic syndrome. It took 30 years to be accepted.

Going back to obesity, the first question should be why do we get fat? The body is very good at regulating its very complex self. It is called homeostasis. The second question should be what is going wrong, and why do people lose the ability to regulate their body fat? Anyone that has studied feedback systems (regulation systems) will know that too many calories is not the cause, because the body will and when its able to regulate overconsumption. The causes are much more specific.

The alternative hypothesis is the carbohydrates in the diet—especially large volumes of refined, easily digestible carbohydrates and in particular the effects of chronic fructose metabolism by the liver. The consumption of large volumes of refined carbohydrates results in high glycemic loads that require high insulin responses. These high insulin responses in turn disrupts the fat regulation process, and over time is marked by higher fasting glucose, weight gain and insulin resistance. Separately, the large quantity of added-sugars overloads the liver, and with increased insulin levels, the fructose is metabolized as saturated fats through an adaptive unregulated process in the liver, and over time, leads to higher triglycerides, lower HDL and weight gain.

I don't really agree with the anonymous poster who said "it has to do with hunger." It has to do with our REACTIONS to hunger.

At some times of the day (morning), if I'm hungry I'll have a glass of water and feel fine with it. At other times of the day (afternoon), I need something to eat. It used to be junk food...and sometimes, it still is. But, generally, my afternoon snack is hummus and crackers or some peanuts.

Last year, I lost 20 pounds, but most of that was due to illness. However, in the fall, I went off of one medication, and noticed I was really craving carbs badly, which meant I was again eating more carbs. Also, it seemed like I was gaining weight no matter what I did (I walked 90 miles one month last fall and still gained 5 pounds that month). So I gained back the 20 pounds in 5 months.

I realized the obvious thing (beyond I was eating more than I should) - I'm now through menopause, so of course I'm going to gain weight a little more easily. I am being more careful again, am not craving carbs quite so much, and am back to really slow weight loss. And have continued to average walking 2 miles a day.

For many people, maintaining an average weight is easy. You're VERY lucky. For many of us, it's hard. To blame JUST the individual or JUST the environment is wrong-headed - weight is a very awkward combination of personal and societal.

I think the problem is as a society we worship food. We celebrate holidays with lots of food. As for consuming 1200 cal/day, that is tough, but that's probably what we should consume if we are sedentary. Nobody wants to take responsibilty for our own outcomes. I knew I had a genetic predisposition to DM. My health habits in medical school, residency, and practice were deplorable. It was no surprise when I started having excessive thirst and polyuria. I was probably doomed from the start genetically, but my own actions brought the phenotype out earlier than I would have liked.

I've lost a significant amount of weight. I am now almost to my high school mass. While I hate Type 2 Diabetes with extreme prejudice, I'm not blaming society and certainly not the damn environment! It is incredibly revealing when you restrict yourself to a strict, carb counting, calorie counting diet just how much total crap (useless calories) one consumes every day. I pass up a piece of cake at the nurses station, avoid snacking, etc.. Does this make like a little less enjoyable? You bet. Did I enjoy sweets and desserts? You bet. Am I surprised at my current condition? Disappointed but not surprised.

As I recall from physiology, <2% of morbid obesity is related to a true "gland problem", other than salivary glands.

To those that say it is not as simple as consume less calories than you burn, I say Bull@@@@! After all, what is the goal of bariatric surgery (other than permanently deranging a perfectly normal GI tract)?

The truth is, eat less calories than you burn. End of story. Is it easy? Hell no! But for thousands of years we lived without this obesity epidemic. Let's look back. People consumed unprocessed food and there was no automation of labor intensive tasks. They burned more calories than the current reality show watching zombies and did not concurretnly pound down a bag of chips or bowel of ice cream. I've been guilty of this myself.

So for you bleeding hearts who say I have no compassion let's look at what the Bible says:

When you sit down with a ruler, note well what is before you, and put a knife to your throat if you a given to gluttony.Proverbs 23:1-2.

Pretty harsh words for those who lack self control when it comes to eating. Seriously ask yourself, "Is it society's fault that I chose to eat the Big Mac instead of the salad?" By the way, I much prefer the Big Mac to the salad to this day. Alas, I can look forward to losing toes, being hooked to a machine that filters the Urea out of my blood, and having a massive MI the day after I pay off my mortage.

You reap what you sow. I loved food and sweets, and with some genetic predisposition, I am definitely reaping the results of my unhealthy decisions.

I don't have a MS in Nutrition. I am only a lowly MD who holds two board certificates and operates on the morbidly obese all the time, and it's not the restrictive type of surgery either. So I guess that disqualifies me from knowing anything on the subject.